2019/20 School Age Child Care Registration (Columbus)

Date

MonthDayYear
Time

:HourMinutesAM/PM Option
2019/20 School Age Child Care Registration

Completion of this registration packet does not complete the enrollment process. You must pay the registration fee (if required) and complete any additional steps as indicated by the Child Care Director or Registrar. Upon completion of this packet and your payment of the registration fee, you will be contacted via email within 5-10 days regarding your status in the requested programs.
If you received a code, enter it here:
Student Name*

First NameLast Name
Nickname - What does the child preferred to be called?
Date of Birth*

MonthDayYear
Gender

MaleFemale
Age Days
Age
School District*
Columbus Schools
SWCS
Session Request?*
Entering Grade in 2018/19*
Most programs serve only K-5
Are you also interested in our Kindergarten Plus program @ Grace Church on the off school days?

YesNo
Kindergarten Plus?
First Day at the Program (Use calendar button. Do not manually enter date.)

MonthDayYear
Child's Favorite Subject
My child interacts easily with
My child has difficulty with
What are effective strategies that you use to redirect your child's behavior?
Are you interested in joining a Parent Advisory Committee?

YesNo
Or could you see yourself being involved by:
Please provide any additional information that you think is important or may affect the child's ability to fully participate in our program.

Parent / Guardian Statement of Understanding and Policies
Policies and Procedures/Handbooks
Acknowledgement of Policies and Procedures I have reviewed and received a copy of the center's policies and procedures/handbook.*

YesNo
Photography/Videography Release: Choose the appropriate response in regards to YMCA staff photographing or videotaping my child for YMCA promotional purposes (ads, brochures, newspapers, recruitment videos,) or for on-site activity purposes*

I give the YMCA staff permission to take my child’s picture for promotional purposes or onsite activities.I do not give the YMCA staff permission to take my child’s picture for promotional purposes or onsite activities.
Signature
The YMCA of Central Ohio’s Employee Code of Conduct related to the interactions between YMCA Staff and program participants, members and volunteers. The YMCA of Central Ohio is committed to keeping its program participants, members, volunteers, staff and the community safe.

We feel that it is important to share with you the expectations that we have of our staff regarding their interactions with program participants, members, volunteers, fellow staff, and the community. Please review and retain a copy of this document describing our expectations.

Financial / Payment Information
Completion of this registration packet does not complete the enrollment process.

You must pay the registration fee (if required) and complete any additional steps as indicated by the Child Care Director or Registrar.

Registration Fee: A registration fee of $30.00 for one child and $50.00 for two or more children is due at the time of registration. The registration fee is non-refundable.

Program Fees: It is my complete understanding that I am responsible for seeing that all payments are complete. Failure to do so may result in dismissal from the program. It is also my complete understanding that if I wish to terminate or change my child care registration in any way, I must provide the YMCA Child Care Registrar Office a 14 day written notice prior to my next payment due date. If proper notice is not received, I will be held responsible for tuition regardless of whether my child attends the program.
Payment
prevnext( X )
One Child$30.00

Two Children or More$50.00
Who is responsible for paying monthly fees?
Name*

First NameLast Name
Birth Date

MonthDayYear
Phone Number*

Area CodePhone Number
E-mail*
I will pay my fees with the following method*

Automatic MonthlyEvery 2 WeeksTitle XX
Is there a second parent splitting the fees with you?

YesNo
How much percent is the second parent paying?
Second Parent Name

First NameLast Name
Second Parent Birth Date

MonthDayYear
Second Parent Phone Number

Area CodePhone Number
Second Parent E-mail
A YMCA staff person will be in contact with you to secure either bank account or credit/debit card information for the draft payment.
Signature

Parent/Guardian 1
Parent/Guardian 1*

First NameLast Name
Relationship to Child*
E-mail*
Cell Phone
Home Phone
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Work/School Name*
Or enter N/A if not applicable
Parent's Work/School Phone*
Parent's Work/School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where would you like to be reached while your child is in the program?

Cell PhoneWork PhoneHome Phone
Contact preference
Where can you be reached while your child is in this program?
Please indicate if this name should be released if a parent/guardian, of a child attending the center/home, requests contact information for other parents/guardians.

YesNo
Should a Second Parent be listed?*

Emergency Contacts/Authorized Pickup

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.
Emergency Contact #1

Required
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Secondary Phone Number*
Relationship to Child*

Emergency Contact #2
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Secondary Phone Number
Relationship to Child

Emergency Contact #3
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Secondary Phone Number
Relationship to Child

Emergency Contact #4
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Secondary Phone Number
Relationship to Child

Plan for Health Conditions
If care is provided for a child who has an ongoing health condition that requires child specific care or may require a medical procedure, the parent/guardian shall complete this form.

A separate plan must be written for each condition that requires different actions to be taken.

If the child has more than 1 medical condition that requires different actions to be taken, answer the fields below for the first condition. Additional conditions must be addressed using this separate form.
Upload additional completed care plans.

Upload a File

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Describe the health condition*
Describe the medical procedure to be completed and expected benefits of treatment*
List activities/foods/environmental conditions to avoid*
Symptoms to watch for and actions to be taken if the symptoms are observed.*
Is any medication required?*

YesNo
In an emergency does this child require additional assistance (more than other children of the same age or in the same group) to evacuate?*

YesNo
Please describe*
In the event that the child care program must be evacuated, are there medications or supplies that must be taken with this child?*

YesNo
Please describe*

Additional Medication
Weight*
Check all that apply

Prescription medication
Nonprescription medication
Refrigeration required
Topical product or lotion
Food supplement
Modified diet
Name of medication*
Exact dosage*
To be administered at the following times*
For the following period of time*
If your child's medication meets any of these criteria:
1. A physician's instruction is needed for a nonprescription medication (e.g. child is underage or underweight per the label instructions); or
2. It is a sample medication without a prescription label; or
- The nonprescription medication is to be given longer than three consecutive days within a fourteen day period or is a topical product or lotion that is being used for a skin ailment and is to be given no longer than fourteen consecutive days; or
1. The child is on a modified diet (an entire food group is eliminated); or
2. The medication contains codeine or aspirin.
Please complete this form and Box 2 must be completed by a licensed physician, licensed dentist, or an advance practice nurse.
Upload a Scanned File of the Completed Form

Upload a File

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Have any additional medications that you need to complete a form for?

Download this form and complete it.

You can upload a saved copy below.
Additional Medication Forms

Upload a File

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The YMCA of Central Ohio has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.*
Type first and last name above to consent
This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by the administrator/designee prior to the child receiving care. After the child is attending the program the administrator shall have the parent/guardian review and initial the form when any changes/updates are made and at least annually. The parent/ guardian and the administrator or designee shall initial and date the form in the section below to indicate when the form was last reviewed.*
Type first and last name above to consent
Sign Document*
Date Signed*

MonthDayYear
Child Care Director and Contact Info

Registration Pin
registraremail
Should be Empty:

2019/20 School Age Child Care Registration

Parent / Guardian Statement of Understanding and Policies

Financial / Payment Information

Parent/Guardian 1

Parent/Guardian 2

Emergency Contacts/Authorized Pickup

Emergency Contact #1

Medical / Health Information

Plan for Health Conditions

Additional Medication